local anesthesia in mohs surgery - esmscourse.org...tumescence local anesthesia (tla) thanks to...
TRANSCRIPT
![Page 1: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/1.jpg)
Local anesthesia in Mohs surgery
![Page 2: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/2.jpg)
• easy to perform
• quick onset
• intraoperative communication
• low side risks
• treatment of risk patients possible
• very low mortality
Advantages
![Page 3: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/3.jpg)
Chemical structure
• similar chemical structures, 3 components
• lipophilic aromatic ring portion:diffusion of the
anesthetic through membranes quick onset
• hydrophilic amin portionlongetivity
• Intermediate chain
- „ester-type“
- „amid-type“
![Page 4: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/4.jpg)
• strong effect
• quick onset
• long lasting
• low toxicity
• low allergy potency
local anesthetic
of amidtype
Ideal local anesthetic agent
Lidocaine
Bupivacaine
Mepivacaine
Prilocaine
Ropivacaine
![Page 5: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/5.jpg)
Surgery of the Skin
Robinson, Hanke et al
local anesthetic agent
![Page 6: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/6.jpg)
Vasoconstrictors
• Adrenaline, Noradrenaline, Phenylephrine
• decrease bleeding
• prolong duration of anesthesia
• minimize the amount of drug injected
• finger, nose, ears
• full vasoconstriction after 7-15 minutes
• 1:100 000
![Page 7: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/7.jpg)
Vasoconstrictors
• since existence of produced Lidocaine with Adrenaline no single
case of digital necrosis Plast Reconstr Surg 2001; 108
• American podiatric society uses Lidocaine with Adrenalin for
many years (200 000 interventions) J Am Podiatr Soc 1971; 61
Plast Reconstr Surg 2001; 107
Ann Plast Surg 1998; 41
• call for complications without any new cases Plast Reconstr Surg 2002; 110 JDDG 2005; 3
![Page 8: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/8.jpg)
Sodium bicarbonate
• reduces the pain on infiltration
pH of lidocaine 5.0-7.0
however, addition of acidic preservatives
lowers the pH to 3.3-5.5 causing more
discomfort with injection 1:5-1:10
• adviseful also in areas of inflammation
![Page 9: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/9.jpg)
Systemic adverse effects
• Psychogenic attacks vasovagal episodes
• Increased parasympathetic tone
• Lightheadness, nausea, syncope,
• bradycardia, hypotension
Trendelenburg position
• Epinephrine reactions
flushing, palpitations, malaise, tachykardia
(but no hypotension!)
![Page 10: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/10.jpg)
• Life threating allergic reactions rare
• More commonly with ester derivates
• No cross reactivity between ester and amide
types
• Often reaction to preservative (Methylparabene)
and not to the anesthetic itself
Systemic adverse effects
![Page 11: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/11.jpg)
Tumescence local anesthesia (TLA)
lat.: “tumescere” = swelling
- subcutaneous
- diluted
- with adrenalin
thanks to Prof. Dr. Matthias Möhrle
Praxisklinik Tübingen - Haut und Venen
Lehrpraxis der Eberhard Karls Universität Tübingen für das
Fachgebiet Dermatologie
![Page 12: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/12.jpg)
Tumescence local anesthesia (TLA)
thanks to Prof. Dr. Matthias Möhrle
![Page 13: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/13.jpg)
Tumescence local anesthesia (TLA)
thanks to Prof. Dr. Matthias Möhrle
Skin Surgery 0,21% (max 4ml/kg)
NaCl 0,9% / Ringer 500,0 ml
Lidocain 2% 50,0 ml
Ropivacain 1% 20,0 ml
Adrenalin Amp 0,5 ml
![Page 14: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/14.jpg)
Tumescence local anesthesia (TLA)
thanks to Prof. Dr. Matthias Möhrle
Injection: Thin needles (27, better 30 Gauge)
slow nearly horizontal injection with manually strongly tensed skin
![Page 15: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/15.jpg)
Tumescence local anesthesia (TLA)
thanks to Prof. Dr. Matthias Möhrle
Advantages
- No buffer needed
- Efficiency equal to 1% Lidocaine
- Slow injection is free of pain
- Low costs, easy to prepare
Disadvantages
- needs more time and space
- changed topography
![Page 16: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/16.jpg)
Advantages
• less local anesthetic agent
• less pain
• longer duration
• topography
Disavantages
• technical expertise
• no vasoconstriction
• risk of nerve injury/
intravascular injection
Nerve blocks
![Page 17: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/17.jpg)
• N. supraorbitalis
Foramen supraorbitale
• N. supratrochlearis
anesthesia of
the ipsilateral forehead
Supraorbital block (V1)
![Page 18: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/18.jpg)
Supraorbital block (V1)
![Page 19: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/19.jpg)
anesthesia of ipsilateral
lower eyelid
lateral nose
cheek
upper lip
N. infraorbitalis
Foramen infraorbitale
Infraorbital block (V2)
![Page 20: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/20.jpg)
cutaneous route
Infraorbital block (V2)
intraoral route
![Page 21: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/21.jpg)
N. mentalis
Foramen mentale
Anesthesia of
ipsilateral lower lip and chin
Mental block (V3)
![Page 22: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/22.jpg)
cutaneous route
Mental block (V3)
intraoral route
![Page 23: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/23.jpg)
no real block
- N. infratrochlearis
- N. infraorbitalis
- N. nasociliaris
Anesthesia of the nose
![Page 24: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/24.jpg)
intraoral block of the N. lingualis
Anesthesia of the ipsilateral tongue
Anesthesia of the tongue
![Page 25: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/25.jpg)
• no real block
• N. auriculotemporalis (preauricular side)
• N. auricularis major (retroauricular side)
• auricular branch of N. vagus (retroauricular side)
Anesthesia of the ear
![Page 26: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/26.jpg)
Anesthesia of the earlobe
![Page 27: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/27.jpg)
• effective block for the finger
• no risk of nerve injury
• anesthesia along flexor tendon sheath
• perpendicularly metacarpal injection
• very fast onset
Transthecal block
![Page 28: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/28.jpg)
Transthecal block
![Page 29: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/29.jpg)
• Use small diameter needles
• Minimize patient viewing of needle/injection
• Add sodium bicarbonate in normal local
anesthesia
• Warm the anesthetic solution
Take home message I
![Page 30: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/30.jpg)
Take home message II
• Inject and infiltrate anesthetic slowly,
deep to more superficial
• Minimize the number of punctures
• Reintroduce needle at previously
anesthetized areas
• Consider TLA or nerve blocks for larger areas
![Page 31: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/31.jpg)
For a patient 2 criterias define the result
of an operation
• Cosmetical result
• Pain before and during the treatment
![Page 32: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/32.jpg)
THANK YOU! [email protected]
![Page 33: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/33.jpg)
He/01
Injection inbetween tendon M. flexor carpi ulnaris
and M. palmaris longus
Ulnar nerve block
anesthesia
• palmar Dig. IV ulnar und Dig. V
• dorsal Dig. III ulnar und Dig. IV/V
![Page 34: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/34.jpg)
anesthesia
• palmar Dig. IV radial
• Dig. II/III und Dig. I ulnar
• dorsal Dig. I Endphalanx
Dig. II/III/ IV radial
Mid/Endphalanx
Injection inbetween
M. palmaris longus and
M. flexor carpi radialis
Median nerve block
![Page 35: Local anesthesia in Mohs surgery - esmscourse.org...Tumescence local anesthesia (TLA) thanks to Prof. Dr. Matthias Möhrle Advantages - No buffer needed - Efficiency equal to 1% Lidocaine](https://reader034.vdocuments.net/reader034/viewer/2022050217/5f62f9181a7b95452f185727/html5/thumbnails/35.jpg)
•Block of Ramus Superficialis/
dorsalis N. radialis
•Injection lateral of A. radialis
Radial nerve block
Anesthesia
• palmar Dig. I radial
• dorsal DigI/II und Dig. III radial